XXY (Klinefelter) Syndrome

Description

Other Names

47,XXY
XXY condition
XXY male
sex chromosome aneuploidy

Diagnosis Coding

ICD-10

Q98.0, Klinefelter syndrome karyotype 47,XXY

Q98.1, Klinefelter syndrome, male with more than two X chromosomes

Q98.4, Klinefelter syndrome, unspecified

ICD-10 for Klinefelter Syndrome provides further coding details.

Description

XXY syndrome is caused by an extra X chromosome in each cell and has a karyotype (chromosome study) of 47,XXY instead of the typical 46,XY male karyotype. The condition can affect male physical, language, and social development. Although the symptoms vary significantly among affected individuals, the most common features are testosterone deficiency and infertility. If testosterone measures low for age in adolescents, regular treatments with testosterone is usually initiated. Affected children with XXY syndrome may require academic, social, and emotional support.

Historically, XXY syndrome was called Klinefelter syndrome due to a constellation of physical and behavioral characteristics that occurred with the chromosome complement of XXY. With time, it became obvious that many males have the "Klinefelter syndrome" chromosome alteration, but do not have the physical and behavioral phenotypes. In addition to the most typical XXY karyotype, other chromosome abnormalities may lead to a similar presentation. These include XY/XXY mosaicism, where a percentage of cells are normal (46,XY), and a percentage have an extra X chromosome (47,XXY). Individuals with mosaicism may still be fertile, depending on the percentage and distribution of normal XY cells. Although less common, it is also possible to have more than 1 extra X chromosome (e.g., 48,XXXY), which is typically associated with a more severe phenotype and intellectual disability.

Prevalence

XXY syndrome is the most common disorder of sex chromosomes, affecting approximately 1/1,000 males. [Morris: 2008] Variants are rarer; 48,XXXY is present in 1/170,000–1/50,000 male births. [Visootsak: 2006]

Genetics

Boys with XXY syndrome inherit an extra X chromosome from either their mother or father during formation of the egg or sperm. About half of the cases are from the maternal chromosomes, half from the paternal chromosomes. This is a chance occurrence, and families with one member with XXY syndrome are not more likely to have other affected family members. Mosaic Klinefelter syndrome (46,XY /47,XXY) usually occurs as an error in cell division in a developing embryo.

Prognosis

Although the range of features is wide, most individuals with XXY will lead normal lives with a normal life expectancy. Boys who have been diagnosed early and who have received developmental therapies, educational interventions, social support, and testosterone therapy may have better outcomes.

Roles Of The Medical Home

The medical home provider will need to monitor maturation, response to testosterone therapy, developmental and educational progress, and patient and family adjustment. When the diagnosis occurs prenatally, it is important to counsel families that reports of developmental and behavioral problems associated with the condition are affected by selection bias, as individuals without developmental problems would not usually be offered genetic testing.

Practice Guidelines

Although not a formal guideline, the following lists age-specific recommendations for the management of individuals with XXY syndrome.

Aksglaede L, Link K, Giwercman A, Jørgensen N, Skakkebaek NE, Juul A.
47,XXY Klinefelter syndrome: clinical characteristics and age-specific recommendations for medical management.
Am J Med Genet C Semin Med Genet. 2013;163C(1):55-63. PubMed abstract / Full Text

Helpful Articles

PubMed search for XXY (Klinefelter) syndrome in children, last 3 years.

Groth KA, Skakkebæk A, Høst C, Gravholt CH, Bojesen A.
Clinical review: Klinefelter syndrome--a clinical update.
J Clin Endocrinol Metab. 2013;98(1):20-30. PubMed abstract / Full Text

Ross JL, Roeltgen DP, Kushner H, Zinn AR, Reiss A, Bardsley MZ, McCauley E, Tartaglia N.
Behavioral and Social Phenotypes in Boys With 47,XYY Syndrome or 47,XXY Klinefelter Syndrome.
Pediatrics. 2012;129(4):769-78. PubMed abstract / Full Text

Savic I.
Advances in research on the neurological and neuropsychiatric phenotype of Klinefelter syndrome.
Curr Opin Neurol. 2012;25(2):138-43. PubMed abstract

Clinical Assessment

Overview

Many men are still diagnosed when, in the midst of leading normal lives, they have a karyotype or chromosome study as part of the workup for infertility. However, when younger children have chromosome testing as part of an evaluation of developmental delay and hypotonia, boys with this condition are being identified as toddlers and preschoolers. The condition is also sometimes identified on prenatal chromosome analysis.

XXY syndrome should be considered in infants and children with developmental delay or in adolescent males who are tall and overweight with fat distributed in a pear-shaped pattern, and who have decreased secondary sexual characteristics in puberty and learning problems.

Screening

Of Family Members

Since this condition typically does not run in families, screening of family members is not recommended.

Presentations

Characteristics of individuals with XXY syndrome evolve with developmental stage:
  • Infants may be described as "easy" babies. They may present with hypotonia and show developmental delays in some or all areas (particularly language).
  • Toddlers may have continued language delays, or they may be diagnosed with sensory integration disorder, auditory processing problems, and autism spectrum disorder.
  • Young boys and teens with XXY syndrome may be taller and less muscular than their male peers.
  • Adolescents may experience normal or delayed puberty but have decreased facial and body hair; smaller, firmer testicles; decreased muscle development; and gynecomastia. Depression and anxiety may occur at this age, aggressive or oppositional behaviors may also be seen.
  • Older teens and adults may not look different from other males their age, except possibly taller. Low levels of testosterone can cause infertility with normal sexual function and a high-pitched voice. Osteoporosis is often found in older teens and adults with XXY syndrome.
Other presentations may include:
  • Hand tremors
  • Decreased activity and endurance level
  • Sleep abnormalities
  • Difficulties in social situations (shy, immature, passive) with low self-esteem
  • Learning problems
  • Expressive greater than receptive language problems
  • Decreased auditory recall
  • Easily frustrated
  • Higher risk of autoimmune diseases in adults

Diagnostic Criteria

Diagnosis is made by karyotype or chromosomal microarray studies.

Differential Diagnosis

Hypogonadotropic hypogonadism: Males with hypogonadotropic hypogonadism have low testosterone due to a failure of gonadotropin release. Hypogonadotropic hypogonadism can be acquired (e.g., secondary to brain trauma) or congenital. Examples of the latter include Kallmann syndrome (hypogonadotropic hypogonadism and anosmia) and idiopathic hypogonadotropic hypogonadism. In these individuals, the gonadotropins luteinizing hormone (LH) and follicle-stimulating hormone (FSH) are low, whereas in individuals with XXY syndrome, they are high. Karyotype results will identify those with XXY syndrome. See Hypogonadotropic Hypogonadism (GeneReviews) for more information.

Fragile X syndrome: Individuals with this syndrome may share some physical characteristics with individuals with XXY including intellectual disability, autistic features, hypotonia, and tall stature. The two conditions may seem more similar in younger children; in general, they can be distinguished much more easily in older children and adolescents. They can be differentiated definitively by genetic testing, which will demonstrate sex chromosome aneuploidy in individuals with XXY. The Portal’s module on Fragile X Syndrome provides further diagnostic and management information.

Marfan syndrome: Individuals with Marfan syndrome, a connective tissue disorder, are tall of stature and may demonstrate hypotonia. Karyotyping will identify males with the XXY syndrome; Marfan syndrome is a clinical or molecular diagnosis based on family history and affected body systems. It is sometimes confirmed with genetic testing for mutations in the FBN1 gene. See Marfan Syndrome (GeneReviews) for more information.

Other overlapping conditions: Especially in younger children, XXY syndrome has a nonspecific presentation that overlaps with many additional genetic conditions, including microdeletion and microduplication syndromes, metabolic disorders such as homocystinuria, and overgrowth disorders such as Sotos syndrome. If routine chromosome studies are normal in a child with features of XXY syndrome, refer for genetic evaluation.

History & Examination

Family History

No family history is expected; XXY syndrome usually occurs sporadically or randomly.

Pregnancy Or Perinatal History

Pregnancy/perinatal course are not affected.

Current & Past Medical History

No significant associations; hypotonia may be a feature.

Developmental & Educational Progress

Children with XXY syndrome may have developmental delays, especially in language development. School performance may be poor specifically in language, and attention problems may be present. [Ross: 2008] Monitor developmental and educational progress and ensure that adequate therapies are in place.

Maturational Progress

Maturation usually begins normally, but unless the individual is receiving testosterone replacement/supplementation, facial and body hair and the expected increase in muscle mass can fail to develop. Maturational progress with the onset of adolescence should be monitored closely by a pediatric endocrinologist. Boys with XXY syndrome are sometimes diagnosed when puberty is delayed. [Zeger: 2008]

Social & Family Functioning

Individuals and their families may need help with adjusting to diagnosis. Boys with XXY may be withdrawn socially and may need social skills training.

Physical Exam

General

Individuals with XXY syndrome may be quiet, and they may have decreased interaction with the examiner.

Growth Parameters

Ht | Wt | BMI Boys are usually tall and may have abnormal body proportions with long legs and a shorter trunk. They can have decreased muscle mass and are often overweight. Weight and BMI should be monitored closely with preventative measures taken to avoid obesity.

Mouth/Teeth

Look for abnormal teeth; teeth may often show taurodontism, which is enlargement of the body and shortening of the roots of the tooth. Enamel defects may also be present. [Ramasamy: 2009]

Chest

Routine breast examinations should be performed on adolescents with XXY syndrome.

Genitalia

Young boys may have a small penis and small firm testes, even after adolescent maturation begins. Micropenis is sometimes seen in boys with XXY syndrome, though it is not common.

Neurologic Exam

Neurologic exam should be normal, yet hypotonia and a resting hand tremor are sometimes present. Although strength may be decreased in males with XXY syndrome, this is difficult to demonstrate on exam. [Ross: 2008]

Testing

Laboratory Testing

Testosterone, luteinizing hormone (LH), follicle-stimulating hormone (FSH) levels, estradiol, prolactin, and insulin-like growth factor (IGF) in the blood may be measured as a baseline and in response to treatment with testosterone. Before treatment, the testosterone level is usually low; LH and FSH levels are usually high.

Genetic Testing

Karyotyping will confirm the diagnosis of XXY syndrome. Typically, chromosomes from approximately 20 cells are counted in standard karyotyping, so a low percentage mosaicism may be missed. Additionally, a karyotype of blood cells reflects the karyotype in olnly one tissue.

Other Testing

Bone density screening should be performed on a regular basis starting in the teen years.

Subspecialist Collaborations & Other Resources

Pediatric Genetics (see Services below for relevant providers)

Consider a consultation for diagnostic testing and family education.

Developmental Pediatrics (see Services below for relevant providers)

Consider for help in evaluating developmental and academic progress and for suggesting therapies as needed.

Pediatric Endocrinology (see Services below for relevant providers)

Consider referral for ongoing management of testosterone therapy.

Treatment & Management

Pearls & Alerts

Fertility treatments

Sperm extractions in conjunction with testosterone therapy have been used with good success to allow fertility in men with XXY syndrome. The treatments are expensive and additional measures, such as intrcytoplasmic sperm injection, may also be needed.

Systems

Endocrine/Metabolism

In most cases, testosterone is measured in adolescents with XXY syndrome. If low for age (not all teenage boys with XXY syndrome will have a low level), treatment is started with testosterone on a regular basis. Testosterone increases facial and body hair, muscle development, and sex drive; it may decrease gynecomastia and osteoporosis risk. Boys with XXY syndrome that are treated with testosterone tend to have higher self-esteem, perhaps because they fit in better with their peers. Attention and concentration may also be improved in these boys. Because low testosterone leads to release of the gonadotropins LH and FSH, these levels are high in untreated individuals with the XXY syndrome.

Treatment is usually initiated at 11 or 12 years of age with testosterone enanthate (Delatestryl) or cypionate (Depo-Testosterone) at 25-50 mg IM q 2 weeks–1 month. It is then increased gradually depending on the degree of virilization, growth, and serum gonadotropin levels, which should decrease with therapy to the high normal range. (Final adult dose is approximately 200 mg IM q 2–3 weeks.)

Once treatment starts, monitor for possible side effects including worsening acne, too rapid sexual development, prostate enlargement, and behavior problems–especially aggression. Transdermal methods of testosterone administration may also be used in older individuals with XXY syndrome.

Note that testosterone therapy does not change the rate of infertility. The option of semen collection and sperm-banking (cryopreservation) in XXY individuals during puberty may be discussed during visits to the geneticist or endocrinologist.

Subspecialist Collaborations & Other Resources

Pediatric Endocrinology (see Services below for relevant providers)

Referral can be helpful for initiation and management of testosterone therapy. Referral to a reproductive specialist may also be helpful in older adolescents and young adults. Referral is often made through the pediatric endocrinologist.

Pediatric Urology (see Services below for relevant providers)

Fertility questions may be addressed by urology.

Development (general)

Developmental delays, if present, should prompt referral to developmental therapies including physical, occupational, and speech/language as clinically indicated.

Subspecialist Collaborations & Other Resources

Developmental Pediatrics (see Services below for relevant providers)

May be helpful in the evaluation and management of developmental delays and behavioral and emotional challenges.

Physical Therapy (see Services below for relevant providers)

May be helpful for addressing gross motor delays and/or lack of abilities and coordination.

Occupational Therapy, Pediatric (see Services below for relevant providers)

May be helpful for fine motor delays and sensory integration problems.

Speech/Language Therapy (see Services below for relevant providers)

May be helpful for the expressive language delay frequently seen in males with XXY syndrome.

Learning/Education/Schools

School progress, including both academics and social functioning should be monitored. If problems are evident, individuals with XXY syndrome should have a comprehensive psychoeducational profile. The medical home provider may need to help the family advocate appropriate educational resources based on this testing.

Subspecialist Collaborations & Other Resources

Psychologist, Child-18 (see Services below for relevant providers)

A full psychoeducational profile to identify strengths, weaknesses, and alternative teaching strategies may be helpful in males with XXY syndrome who are having difficulties in school.

Maturation/Sexual/Reproductive

Males with this syndrome are likely infertile, and may need to use alternative methods to father children. Males with XXY syndrome usually have normal sexual function and will need to be counseled as adolescents about the use of barrier methods for prevention of sexually transmitted diseases. Males with mosaic XXY syndrome may still be fertile and will need to be counseled for contraception as is usual in the practice of the medical home provider for adolescents.

Subspecialist Collaborations & Other Resources

Pediatric Urology (see Services below for relevant providers)

May be helpful in answering questions and managing infertility in males with XXY syndrome.

Mental Health/Behavior

Individuals and their families may need help adjusting to this diagnosis. Some boys or young men will be concerned about the risk of infertility; it is important to validate and address this concern. Some boys will be embarrassed about having an “extra” X chromosome and may feel this makes them less male or partially female. However, XXY syndrome is not an intersex condition and does not lead to an increased likelihood for males to identify as females.

The personality and behavior of boys with XXY syndrome has been described as shy, reserved, sensitive, and passive in childhood, which together with unattended learning difficulties may lead to secondary adaptation and behavioral problems in adolescence. [Sørensen: 1992] [Ross: 2008] Testosterone treatment from puberty may assist in psychosocial adaption during adolescence.[Simm: 2006] [Maggi: 2007] Social skills training, special education services, or provisions in an individualized educational plan for learning problems may also help improve self-esteem. [Samango-Sprouse: 2002] Sometimes, having a diagnosis can help qualify children for services. More details about the personal impact of XXY syndrome and the influence of age at diagnosis, clinical, social, and demographic factors on adult quality of life outcomes can be found in [Herlihy: 2011].

Subspecialist Collaborations & Other Resources

Developmental - Behavioral Pediatrics (see Services below for relevant providers)

Referral may be helpful for social skills training and behavioral problems.

Family Counseling (see Services below for relevant providers)

Referral may help families and individuals adjust to diagnosis.

Mental Health Counselors (LPC, CMHC) (see Services below for relevant providers)

Referral may be helpful in improving body image, self-esteem, mental health, and social supports.

Transitions

Adult males with XXY syndrome have an increased risk of osteoporosis, breast cancer, extragonadal germ cell tumor, varicose veins, and lung disease. They also have an increased risk of autoimmune disease compared to the general population (including thyroiditis, lupus, and type 1 diabetes). Teens with XXY syndrome who are transitioning to adult care should be made aware of symptoms for these conditions and appropriate screening should be performed as necessary. The Portal's page on Finding Adult Health Care discusses the roll of the medical home during this transition process and provides information to families about how to find a doctor who will meet the transitioning child's medical needs.

Frequently Asked Questions

Should all boys with gynecomastia be tested for XXY syndrome?

Gynecomastia is common among adolescent boys. If puberty is otherwise proceeding normally, including normal testicular growth, XXY syndrome is unlikely.

Can I send testing for XXY syndrome, or does it need to be sent by a specialist?

A routine chromosome study can usually be sent from a primary care provider’s office. However, most insurance companies require prior authorization for genetic testing.

Is a karyotype (G-banded chromosome study) or a microarray the best test for XXY syndrome?

It depends on how the patient presents. Either test will detect XXY syndrome. If you have a high concern for 47,XXY and don’t suspect another condition (as in a teenager with gynecomastia and small testes for Tanner stage), a karyotype will probably be sufficient. The microarray, though more expensive, is a more sensitive test for other chromosome abnormalities. It can be considered as a first step in boys with developmental delay or as a second step for children whose chromosome study is normal, but XXY is still suspected. Prior authorization may be needed for these tests.

Issues Related to XXY (Klinefelter) Syndrome

Resources

Information for Clinicians

Klinefelter & Other Sex Chromosomal Aneuploidies (OJRD)
Diagnosis and management information with short descriptions of 48,xxyy, 48,xxxy, 49,xxxxy, and 46,xx; Orphanet Journal of Rare Diseases.

Genetics in Primary Care Institute (AAP)
The goal of this site is to increase collaboration in the care of children with known or suspected genetic disorders. Includes health supervision guidelines and other useful resources; a collaboration among the Health Resources & Services Administration, the Maternal and Child Health Bureau, and the American Academy of Pediatrics.

Helpful Articles

PubMed search for XXY (Klinefelter) syndrome in children, last 3 years.

Groth KA, Skakkebæk A, Høst C, Gravholt CH, Bojesen A.
Clinical review: Klinefelter syndrome--a clinical update.
J Clin Endocrinol Metab. 2013;98(1):20-30. PubMed abstract / Full Text

Ross JL, Roeltgen DP, Kushner H, Zinn AR, Reiss A, Bardsley MZ, McCauley E, Tartaglia N.
Behavioral and Social Phenotypes in Boys With 47,XYY Syndrome or 47,XXY Klinefelter Syndrome.
Pediatrics. 2012;129(4):769-78. PubMed abstract / Full Text

Savic I.
Advances in research on the neurological and neuropsychiatric phenotype of Klinefelter syndrome.
Curr Opin Neurol. 2012;25(2):138-43. PubMed abstract

Clinical Tools

Patient Education & Instructions

A Guide to Klinefelter Syndrome (AAKSIS)
Two-page brochure introducing basic concepts about the condition; American Association for Klinefelter Syndrome Information & Support.

What is Klinefelter Syndrome? (GSLC)
A brief overview of the genetics of Klinefelter (XXY) syndrome; Genetic Science Learning Center at the University of Utah.

Information & Support for Families

Family Diagnosis Page

Information on the Web

Klinefelter Syndrome (Genetics Home Reference)
Excellent, detailed review of condition for patients and families; U.S. National Library of Medicine.

XXY Syndrome (MedlinePlus)
Brief information about causes, symptoms, tests, treatment, possible complications, and support groups; U.S. National Library of Medicine.

Klinefelter Syndrome (GARD)
Information about cause, inheritance, treatment, and more of Klinefelter or XXY syndrome; Genetic and Rare Diseases Information Center.

Support National & Local

Klinefelter Syndrome Support Group
Links to support groups, information sources, and studies; started by a man who was not diagnosed with XXY syndrome until adulthood.

XXY Syndrome Support Group (AAKAIS)
Lists local support groups and meeting schedules; American Association for Klinefelter Syndrome Information and Support.

Services for Patients & Families

Developmental - Behavioral Pediatrics

See all Developmental - Behavioral Pediatrics services providers (5) in our database.

Developmental Pediatrics

See all Developmental Pediatrics services providers (5) in our database.

Family Counseling

See all Family Counseling services providers (264) in our database.

Mental Health Counselors (LPC, CMHC)

See all Mental Health Counselors (LPC, CMHC) services providers (308) in our database.

Occupational Therapy, Pediatric

See all Occupational Therapy, Pediatric services providers (42) in our database.

Pediatric Endocrinology

See all Pediatric Endocrinology services providers (2) in our database.

Pediatric Genetics

See all Pediatric Genetics services providers (5) in our database.

Pediatric Urology

See all Pediatric Urology services providers (2) in our database.

Physical Therapy

See all Physical Therapy services providers (62) in our database.

Psychologist, Child-18

See all Psychologist, Child-18 services providers (151) in our database.

Speech/Language Therapy

See all Speech/Language Therapy services providers (80) in our database.

For other services related to this condition, browse our Services categories or search our database.

Authors

Authors: Karin Dent, MS, CGC - 8/2014
Lynne M Kerr, MD, PhD - 1/2014
Reviewing Author: Sarah L. Dugan, MD - 4/2015
Content Last Updated: 6/2015

Bibliography

Aksglaede L, Link K, Giwercman A, Jørgensen N, Skakkebaek NE, Juul A.
47,XXY Klinefelter syndrome: clinical characteristics and age-specific recommendations for medical management.
Am J Med Genet C Semin Med Genet. 2013;163C(1):55-63. PubMed abstract / Full Text

Groth KA, Skakkebæk A, Høst C, Gravholt CH, Bojesen A.
Clinical review: Klinefelter syndrome--a clinical update.
J Clin Endocrinol Metab. 2013;98(1):20-30. PubMed abstract / Full Text

Herlihy AS, McLachlan RI, Gillam L, Cock ML, Collins V, Halliday JL.
The psychosocial impact of Klinefelter syndrome and factors influencing quality of life.
Genet Med. 2011;13(7):632-42. PubMed abstract
Investigates the personal impact of Klinefelter syndrome and the influence of age at diagnosis, clinical, social, and demographic factors on adult quality of life outcomes.

Maggi M, Schulman C, Quinton R, Langham S, Uhl-Hochgraeber K.
The burden of testosterone deficiency syndrome in adult men: economic and quality-of-life impact.
J Sex Med. 2007;4(4 Pt 1):1056-69. PubMed abstract

Morris JK, Alberman E, Scott C, Jacobs P.
Is the prevalence of Klinefelter syndrome increasing?.
Eur J Hum Genet. 2008;16(2):163-70. PubMed abstract

Ramasamy R, Ricci JA, Palermo GD, Gosden LV, Rosenwaks Z, Schlegel PN.
Successful fertility treatment for Klinefelter's syndrome.
J Urol. 2009;182(3):1108-13. PubMed abstract

Ross JL, Roeltgen DP, Kushner H, Zinn AR, Reiss A, Bardsley MZ, McCauley E, Tartaglia N.
Behavioral and Social Phenotypes in Boys With 47,XYY Syndrome or 47,XXY Klinefelter Syndrome.
Pediatrics. 2012;129(4):769-78. PubMed abstract / Full Text

Ross JL, Roeltgen DP, Stefanatos G, Benecke R, Zeger MP, Kushner H, Ramos P, Elder FF, Zinn AR.
Cognitive and motor development during childhood in boys with Klinefelter syndrome.
Am J Med Genet A. 2008;146A(6):708-19. PubMed abstract

Samango-Sprouse, C.
XXY: The Hidden Disability and a Prototype for an Infantile Presentation of Developmental Dyspraxia (IDD.
Infants Young Child. 2002(15):11-18. PubMed abstract

Savic I.
Advances in research on the neurological and neuropsychiatric phenotype of Klinefelter syndrome.
Curr Opin Neurol. 2012;25(2):138-43. PubMed abstract

Simm PJ, Zacharin MR.
The psychosocial impact of Klinefelter syndrome--a 10 year review.
J Pediatr Endocrinol Metab. 2006;19(4):499-505. PubMed abstract

Sørensen K.
Physical and mental development of adolescent males with Klinefelter syndrome.
Horm Res. 1992;37 Suppl 3:55-61. PubMed abstract

Visootsak J, Graham JM Jr.
Klinefelter syndrome and other sex chromosomal aneuploidies.
Orphanet J Rare Dis. 2006;1:42. PubMed abstract / Full Text

Zeger MP, Zinn AR, Lahlou N, Ramos P, Kowal K, Samango-Sprouse C, Ross JL.
Effect of ascertainment and genetic features on the phenotype of Klinefelter syndrome.
J Pediatr. 2008;152(5):716-22. PubMed abstract